Elbow UCL Repair Surgery

UCL Repair Surgery of the elbow (ulnar collateral ligament reconstruction) is a treatment option for the symptomatic, deficient UCL of the elbow. It’s indicated in chronic pain or instability without improvement after at least 4 to 6 weeks of supervised conservative treatment.

The ulnar collateral ligament is the primary restraint to valgus stresses placed on the elbow. Injury to this ligament can occur from traumatic events or through attritional changes commonly seen in overhead athletes leading to pain and discomfort.

See Also: Elbow Anatomy

Important Technical Points

There are a few important technical points to remember when performing UCL repair surgery:

• Calcification should be removed from the ligament.
• Drill holes must correspond to ulnar collateral ligament attachment sites.
• The graft should not rub on the epicondyle or ulna, and the ends of the graft should be buried in the tunnels.
• A figure-of-eight configuration of the graft ensures strength and approximates ulnar collateral ligament biomechanics.
• Meticulous handling of medial antebrachial cutaneous and ulnar nerves, their branches, and their vasculature is essential.

See Also: Elbow Dislocation

Elbow UCL Repair Surgery Steps (Jobe Technique)

• Apply a pneumatic tourniquet.
• Place the arm on an armboard with the elbow extended and put a rolled towel beneath it. If appropriate, prepare the contralateral arm and ipsilateral leg for graft harvest.
• Make a 10-cm incision over the medial epicondyle.
• Protect the medial antebrachial cutaneous nerve and incise the common flexor pronator mass at the posterior third to expose the ulnar collateral ligament.
• Split the muscle, but do not take it down, and incise the ulnar collateral ligament to evaluate the quality of the ligament and joint.
• Lightly retract the ulnar nerve until it is off the bone to allow for drilling of the holes. Do not transfer the nerve.
• Using a 3.2-mm bit at slow speed with a tissue protector, drill anterior and posterior holes in the proximal ulna. Leave a 1-cm bone bridge. Drill the tunnel at the level of the coronoid tubercle. In the medial epicondyle, drill a common anterior hole at the origin of the ulnar collateral ligament for 1 cm using a 4-mm drill. Then, with a 3.2-mm drill bit, make divergent tunnels (lazy “Y”) exiting anterior to the intermuscular septum 0.5 cm apart.
• Obtain a graft 15 cm long from the palmaris longus tendon, plantaris tendon, or Achilles tendon. Place a 1-0 nonabsorbable suture through each end of the graft and thread it through the tunnels in a figure-of-eight fashion.
• Remove the rolled towel from beneath the elbow. Tension and suture the graft with the elbow in neutral (varus-valgus) and 45 degrees of flexion. Evaluate the range of motion. Suture the graft to the remnants of the ulnar collateral ligament.
• If ulnar nerve symptoms and heavy scar tissue are found, ulnar nerve transposition may be necessary. Elevate the flexor pronator musculature, leaving a ring of soft tissue on the medial epicondyle. Decompress the nerve proximally to the arcade of Struthers and distally to the end of the intermuscular septum, avoiding devascularization. Transfer the nerve anterior to the epicondyle and reattach the flexor pronator mass to the epicondyle superficial to the transferred nerve.
• Release the tourniquet and obtain hemostasis. Bathe the nerve with dexamethasone (Decadron) solution and perform routine subcutaneous and skin closure.
• Apply a padded posterior splint with the elbow in 90 degrees of flexion and neutral rotation, leaving the wrist and hand free.

Aftercare

• After UCL repair surgery, the elbow is immobilized in the posterior splint for 10 days. 
• Gentle hand grip exercises are begun as soon as the patient is comfortable. 
• Active range-of-motion exercises for the elbow and shoulder are started at 10 days, and exercises to strengthen the muscles of the wrist and forearm are begun at 4 to 6 weeks. 
• After 6 weeks, elbow strengthening exercises are begun, but valgus stress on the elbow is avoided until 4 months postoperatively. 
• Athletes can begin a progressive, supervised throwing program. 
• They continue with a progressive strengthening program for the forearm and shoulder and a general conditioning program. 
• They are allowed to return to competitive pitching in approximately 1 year.

References & More

1. Morrey BF, An KN. Articular and ligamentous contributions to the stability of the elbow joint. Am J Sports Med. 1983;11:315–319. doi: 10.1177/036354658301100506. [PubMed]
2. Torres SJ, Limpisvasti O. Ulnar Collateral Ligament Repair of the Elbow -Biomechanics, Indications, and Outcomes. Curr Rev Musculoskelet Med. 2021 Apr;14(2):168-173. doi: 10.1007/s12178-021-09698-4. Epub 2021 Feb 9. PMID: 33559839; PMCID: PMC7991021. [PubMed]
3. Erickson BJ, Harris JD, Chalmers PN, Bach BR Jr, Verma NN, Bush-Joseph CA, Romeo AA. Ulnar Collateral Ligament Reconstruction: Anatomy, Indications, Techniques, and Outcomes. Sports Health. 2015 Nov-Dec;7(6):511-7. doi: 10.1177/1941738115607208. Epub 2015 Sep 22. PMID: 26502444; PMCID: PMC4622381. [PubMed]